Pediatrics Review for EM In Service Exam - University at Buffalo ...

Pediatrics Review for EM In 

Service Exam 

Michael Falk 

Fellow Pediatric Emergency Medicine 

Women & Children’s s Hospital of Buffalo

Lecture Goals and Outline 

• To do a general review of Pediatric 

Emergency Medicine cases 

• To do this in a format that is similar to the 

one that you will have on your in service 

exam 

• To review images that are typical of a 

number of common or “classic” pediatric 

illnesses/conditions

Case # 1: Abdominal pain 

• You are working in a Community ER and 

seeing an 14 mo male who presents with 

abdominal pain. The parents state it started 

last night and he has had intermittent 

episodes (15-30 mins) of crampy abd pain. 

Associated with this is two episodes of 

vomiting. 

Given the history, you decide to get an 

abdominal x-ray, x 

what is your diagnosis

Copyright ©Radiological Society of North America, 1999 

del-Pozo, G. et al. Radiographics 1999;19:299-319

Case #1 

a) Gastroenteritis 

b) Small bowel obstruction 

c) Intussusception 

d) Constipation







del-Pozo, G. et al. Radiographics 1999;19:299-319 

Copyright ©Radiological Society of North America, 1999





Case #2 

A 1 week-old male is brought into the ER by his 

parents who state that the patients has poor feeding, 

pallor, diaphoresis and increased somnolence. 

On exam the pt has a hr=180, rr=90 and 

bp=50/30..Breath sounds are shallow, and auscultation 

of the heart reveals a gallop rhythm. The liver is 3cm 

below the costal margin. The baby appears pale and 

mottled, with cool extremities and poor peripheral 

pulses and delayed cap refill (3-4 4 seconds). 

You decide to give NS at 20cc/kg and the hr increases 

to 194 beats/min. Which of the following is the most 

appropriate next step

Case #2 

a) Adenosine at 50 mcg/kg 

b) CT scan of the head 

c) Dopamine infusion at 10mcg/kg/minute 

d) LP followed by antibiotics 

e) 2 bolus of MS at 20cc/kg

Case #2 

• Why can patients like this take a week to 

present 

• Why did the NS bolus increase his hr and 

make the patients worse This is based on 

which principle/mechanism 

• What are the three most common cyanotic 

and noncyanotic congenital cardiac lesions

Case #2 

• Cyanotic 

– Tetralogy of Fallot 

– Transposition of the 

great vessels 

– TAPVR 

• Acyanotic 

– VSD 

– ASD 

– PDA 

– Aortic stenosis

Case #3 

• EMS brings in a 5 mo male after being called to 

his home by the mother. She reports that the baby 

fell out of the crib and starting crying. When she 

picked the patient up, she noticed obvious 

swelling to the thing and the baby screamed when 

that leg is touched. 

The baby is obviously uncomfortable and has 

swelling of the midthigh. The X-ray X 

shows:


Lonergan, G. J. et al. Radiographics 2003;23:811-845

Case #3 

Given this x-ray x 

your next steps should be: 

a) Call ortho and admit the patient 

b) Call ortho, admit the patient and leave it 

up to the pediatric service to call CPS 

c) Call Ortho, admit the patient and call CPS 

to file a report





Recognizing Child Abuse and 

Neglect 

• Fracture that are inconsistent with age or 

what you are told happened 

• Inconsistencies in the parents stories or 

multiple changes to their story 

• Bruises that are note on unusual areas (the 

back, abdomen, thighs, buttocks) or injuries 

with characteristic patterns 

• Any sexually transmitted disease in a 

prepubertal or “not” sexually active child

Case #4 

Parents bring in a 3 month old girl who they 

report is sleepy and “not acting right”. . They tell 

you that she has had a cold for the last two days 

and has been crying a lot at night and congested. 

There is no other significant history and the birth 

history was unremarkable. 

On exam t=38, p=150’s, rr=48 and the bp is not 

obtained. The patient is obviously congested and 

sleeping. While you are examining the patient, 

the baby has a prolonged period of apnea with 

cyanosis and bradycardia.

Case #4 

What would you like to do next 

a) nothing, its periodic breathing and is normal 

b) Start oxygen and monitor the patient 

c) Put the patient on a cardiac monitor and get an 

x-ray 

d) Intubate the patient using RSI protocol and get 

a CT of the head 

e) Oxygen, monitoring and CT scan of the head











Case #4 

• “Shaken-Baby” syndrome can present with a 

variety of presentation-from irritability to 

shock in infants less than 1 year of age 

• Bloody taps are highly sensitive for cranial 

hemorrhage unless traumatic tap is 

suspected, if worried CT!! 

• Remember: in adults head bleeds do not 

present as hypovolemic shock, but this is 

NOT true of infants

Case #5 

• 11 year old male is brought in to the ED by 

his mom because he has a 2 week history of 

knee pain and limp. 

On exam he is over weight and otherwise 

healthy. On exam his knee is unremarkable 

but he has limitation of the hip to internal 

rotation and abduction. No other abn’s 

noted.

Case #5 

• What is the most likely diagnosis 

a) Transient synovitis 

b) Septic arthritis 

c) Legg-Calve 

Calve-Perthes 

d) Slipped capital femoral epiphysis 

e) Rheumatoid arthritis

Case #5 

What single test, will best diagnose this 

condition 

a) ultrasound 

b) CT 

c) X-ray 

d) MRI

Key points for Slipped Capital 

Femoral Epiphysis 

• Occurs in males 2-4X 2 

more often than females 

and they are usually obese and between 8 and 15 

years of age 

• Present with hip or knee pain, or with a limp 

• R of M exam of hip usually shows limited internal 

rotation, abduction, and with flexion, and pain 

with R of M exercises 

• Need both AP and frog-leg view to ensure the 

diagnosis because slip more easily seen in frog- 

leg view 

• Can be bilateral in up to 25% of all SCFE

Case #6 

5 week old male presents to your ER with a 

history of vomiting that has worsened over the 

last week. It started about 5 days ago and has 

progressed till today when the pt will vomit every 

time he feeds and the parents describe it as a 

“huge” amount. 

On exam: the hr=196, rr=48, bp =60/30 and cap 

refill is 4 secs. The baby is pale and mottled in 

the extremities and has nothing else on the exam, 

except for the tachycardia.

Case #6 

What electrolytes would you expect to see 

when you check the patients chemistry 

a) Na=140, Cl=100, Co2=23 and k=3.9 

b) Na=140, Cl=85, Co2=34 and K=3.9 

c) Na=140. Cl=80, Co2=34 and K=2.5 

d) Na=140, Cl=100, Co2=23 and K=2.5

Case #6 

• Pyloric Stenosis is 4 times more likely in males 

than females and usually occurs in the 1 st born 

child 

• Increase incidence if the child's mother had as an 

infant 

• Often present with dehydration and 

hypochloremic, hypokalemic metabolic alkalosis 

• Ultrasound is the test of choice for diagnosis 

(pylorus canal > 1.4 cm or >3mm width of 

circular muscle)

Case #7 

6 year old girls is seen by you in the ED 

and has a 3 day history of URI symptoms 

and low grade fevers. What is this rash 

a) Erythema infecftiosum 

b) Scarlet fever 

c) Infectious mononucleosis 

d) Roseola 

e) Systemic lupus erthematosus

Case #8 

Parents have brought I a 6 year old male 

with a rash over his whole body. He had a 

cold about 5 days ago and fevers were never 

greater than 39 C. Since then he has 

developed vesicular lesions, that started on 

the trunk and head and have now spread to 

cover most of his body. They are very itchy 

and you notice vesicular lesions of various 

age on exam.

Case #8 

This type pf rash is most consistent with 

which disease: 

a) Roseola 

b) Scarlet fever 

c) Measles 

d) Pityriasis rosea 

e) varicella

Case #8 

• Varicella is caused by a herpes virus, that has 

become relatively uncommon due to vaccination 

• Usually presents with prodromal illness and the 

characteristic rash appears with 24 hours of the 

prodrome 

• Rash is characteristically vesicular in nature and 

presents in “crops”,, thus there will always be 

lesions of various ages on one patient 

• Rash usually starts on the upper trunk, face or 

neck and spread centripedally 

• IT ALWAYS is pruritic

In Conclusion 

• Resources: 

– University of Hawaii on line course PEM 

radiology, 

http://www.hawaii.edu/medicine/pediatrics/pe 

mxray/pemxray.html 

– Atlas of Pediatric Emergency Medicine, Shah 

& Lucchesi 

– Textbook of Pediatric Emergency Medicine, 

Fleischer 

– PREP curriculum Self-Assessment guides

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